In a preterm infant with a bronchopleural fistula on ventilation, which therapy is recommended?

• A. Exogenous surfactant therapy
• B. Volume control ventilation
• C. High frequency ventilation
• D. Nitric oxide therapy

Answer: (C)

When a preterm infant has a bronchopleural fistula, the goal is to minimize the air leaking through the fistula while still providing adequate gas exchange. High-frequency ventilation achieves this by delivering very small tidal volumes at a rapid rate, which keeps peak airway pressures and pressure swings low. The small breaths transmit much less pressure to the fistula, reducing the driving force for air to escape into the pleural space and helping the fistula to heal. At the same time, mean airway pressure is adjusted to keep the lungs recruited without the large tidal volumes that can worsen the leak.

Exogenous surfactant helps improve alveolar stability but does not specifically address the fistula or the problem of air leak, and conventional volume-controlled ventilation can produce higher pressures and volumes that may exacerbate the leak. Nitric oxide helps with oxygenation and pulmonary vasodilation but does not reduce the fistula itself. So the single most appropriate strategy in this scenario is high-frequency ventilation.